What Is the Best Initial Therapy for the Average Patient with Idiopathic Achalasia?

200 ARTICLE SUMMARY This case series reports the outcomes of 98 consecutive patients with achalasia who were treated with laparoscopic Heller myotomy. Though not explicitly detailed, the patients are implied to have had classic idiopathic achalasia, based on history and standard manometric and barium imaging criteria. Fifty-nine patients had previously undergone pneumatic dilation, and eight patients had received at least one botulinum toxin injection into the lower esophageal sphincter (LES) muscle. The surgical techniques are described in detail. There was clearly a learning curve – the duration of both surgery and hospital stay significantly decreased as experience was gained. However, overall operative results were good from the beginning. No cases required conversion to an open procedure, and only one mucosal perforation occurred, which was closed laparoscopically without complications. Postoperative complications resolved with supportive therapy and were considered minor. Ninety-one of the 98 patients underwent anterior fundoplication at the time of the myotomy. The reasons for not performing a fundoplication in the other seven patients were not identified, and while these patients were said to have similar improvement in symptom relief and esophageal transit compared with those who underwent anterior fundoplication, specific long term follow-up was not described. Eighty-nine patients were available for postdischarge follow-up, with a median follow-up of 18 months. The reasons for dropouts and the short term outcomes for patients not included in the follow-up group were not disclosed. Only one patient continued to have regurgitation more than once a week after surgery. Two patients continued to have significant dysphagia postoperatively. Both symptoms had been prominent in nearly all patients preoperatively. One of the dysphagic patients required laparoscopic takedown of the fundoplication, while the other responded to balloon dilation of the distal esophagus. Preoperative and postoperative standardized scintigraphic esophageal transit studies were obtained in 67 patients. There was statistically significant improvement in esophageal transit in both the early and the late postoperative follow-up studies. Eighty-seven of 89 patients reported being very satisfied with the surgical outcome. One patient was somewhat satisfied, and one was not at all satisfied.